Basic Information
| Provider Information | |||||||||
| NPI: | 1982165320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARIBEAU | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | SAC-IT. LPC-IT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE DR | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548437800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7159345554 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 STEIN BLVD STE B | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547012674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158360064 | ||||||||
| FaxNumber: | 7158360065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 4772 | WI | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 4772 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 4772-226 | 01 | WI | LPC-IT | OTHER | 18832-130 | 01 | WI | SAC-IT | OTHER |